Schaetti et al. BMC Medicine 2013, 11:206 http://www.biomedcentral.com/1741-7015/11/206 Medicine for Global Health RESEARCH ARTICLE Open Access Comparing sociocultural features of cholera in three endemic African settings Christian Schaetti1,2, Neisha Sundaram1,2, Sonja Merten1,2, Said M Ali3, Erick O Nyambedha4, Bruno Lapika5, Claire-Lise Chaignat6, Raymond Hutubessy7 and Mitchell G Weiss1,2* Abstract Background: Cholera mainly affects developing countries where safe water supply and sanitation infrastructure are often rudimentary. Sub-Saharan Africa is a cholera hotspot. Effective cholera control requires not only a professional assessment, but also consideration of community-based priorities. The present work compares local sociocultural features of endemic cholera in urban and rural sites from three field studies in southeastern Democratic Republic of Congo (SE-DRC), western Kenya and Zanzibar. Methods: A vignette-based semistructured interview was used in 2008 in Zanzibar to study sociocultural features of cholera-related illness among 356 men and women from urban and rural communities. Similar cross-sectional surveys were performed in western Kenya (n = 379) and in SE-DRC (n = 360) in 2010. Systematic comparison across all settings considered the following domains: illness identification; perceived seriousness, potential fatality and past household episodes; illness-related experience; meaning; knowledge of prevention; help-seeking behavior; and perceived vulnerability. Results: Cholera is well known in all three settings and is understood to have a significant impact on people’s lives. Its social impact was mainly characterized by financial concerns. Problems with unsafe water, sanitation and dirty environments were the most common perceived causes across settings; nonetheless, non-biomedical explanations were widespread in rural areas of SE-DRC and Zanzibar. Safe food and water and vaccines were prioritized for prevention in SE-DRC. Safe water was prioritized in western Kenya along with sanitation and health education. The latter two were also prioritized in Zanzibar. Use of oral rehydration solutions and rehydration was a top priority everywhere; healthcare facilities were universally reported as a primary source of help. Respondents in SE-DRC and Zanzibar reported cholera as affecting almost everybody without differentiating much for gender, age and class. In contrast, in western Kenya, gender differentiation was pronounced, and children and the poor were regarded as most vulnerable to cholera. Conclusions: This comprehensive review identified common and distinctive features of local understandings of cholera. Classical treatment (that is, rehydration) was highlighted as a priority for control in the three African study settings and is likely to be identified in the region beyond. Findings indicate the value of insight from community studies to guide local program planning for cholera control and elimination. Keywords: Endemic cholera, Sociocultural features, Community study, Eastern Africa * Correspondence: [email protected] 1Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, PO Box, 4002, Basel, Switzerland 2University of Basel, Petersplatz 1, 4003 Basel, Switzerland Full list of author information is available at the end of the article © 2013 Schaetti et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Schaetti et al. BMC Medicine 2013, 11:206 Page 2 of 16 http://www.biomedcentral.com/1741-7015/11/206 Background studied with reference to the local vantage point of Cholera is an ancient enteric disease that originated community experience. The public health importance of from the Ganges delta [1]. It is caused by the bacterium cholera with reference to professional indicators has Vibrio cholerae that exists in the aquatic environment been extensively studied (that is, disease-related mor- independent from human hosts [2,3]. V. cholerae pro- bidity and mortality, characterization and distribution of duces an enterotoxin, which is the direct cause of acute pathogens, classical epidemiologic risk factors, economic watery diarrhea in humans. Cholera is characterized by costs and so on) [2-4,11,17-19]. It is widely recognized loss of large volumes of rice-water-like stool leading to that cholera can spread rapidly and easily within countries severe dehydration and concurrent electrolyte depletion (for example, Kenya [20]) and across continents. Official [4]. Case fatality rates without treatment may reach 50% WHO policy recommends the development of ‘national [5]. Timely administration of oral rehydration solutions and subregional action plans that include cross-border or infusions is the principal treatment [6]. collaboration […] to enhance multidisciplinary prevention, and preparedness and response activities’ for effective Global cholera burden and sub-Saharan Africa as a hotspot cholera control [15]. Cholera case estimates officially reported to the World In contrast with public health professionals, commu- Health Organization (WHO) ranged between 190,000 nities may prioritize other issues. Lay people may care and 320,000 for the years 2008, 2009 and 2010, and more about illness-related costs than morbidity, and between 5,000 and 7,500 deaths were reported [7-9]. they may perceive the risk of illness with reference to These figures, however, are highly under-reported their local rather than regional experiences. Community because of limitations in surveillance, including case perceptions of the causes of illness may also differ from definitions, and also fear of trade-related and travel- professional concepts, and this may affect their per- related sanctions; they likely represent less than 10% of ceived relevance and value of recommended strategies the true burden [10]. A recent study estimated the for control. Neglecting or underestimating local socio- number of people at risk of endemic cholera globally at cultural aspects of cholera and priorities for control may 1.4 billion, with an annual burden of endemic cholera of limit the effectiveness of interventions and control 2.8 million cases and 91,000 deaths [11]. Cholera thrives programs [21-23]. This point has been elaborated in a mostly in low-income and middle-income countries in review of social science research on neglected tropical Africa, Asia and the Caribbean [12]. diseases of poverty, which highlights the ‘importance of According to the latest estimates, 39% of the popula- community participation for the successful introduction, tion in sub-Saharan Africa lived without safe water in acceptability, and adherence of innovative vector control 2010 (vs 51% in 1990), with an urban share of 17% and a interventions and new drugs and diagnostics’ [24]. rural share of 51% [13]. Use of improved sanitation in Notwithstanding the acknowledged importance of the same region has been increasing from 26% to 30% community-based studies, there are very few in Africa. since 1990. Similar to the estimates on water supply, Some have considered questions about perceived vulner- there is also an urban/rural divide: 43% of urban people ability and social and environmental aspects of cholera benefited from improved sanitation in 2010 versus only [23,25], but systematic assessment of cholera-related 23% in rural areas. experience, meaning and behavior is lacking. In res- The public health burden of cholera is still intolerable ponse to this dearth of community-based research, in sub-Saharan Africa despite the above noted progress three sociocultural field studies were undertaken in a in the provision of safe water and sanitation. Conse- WHO initiative to examine local urban and rural fea- quently, and because of the recent huge outbreaks in tures of cholera and community willingness to accept an Zimbabwe, Pakistan and Haiti, the 64th World Health OCV in eastern Africa. A project in Zanzibar (Tanzania) Assembly adopted a new resolution in 2011 to streng- examined sociocultural features of cholera with a se- then the global fight against cholera [14]. mistructured interview and estimated anticipated accept- The WHO recommends provision of sufficient, safe ance and uptake of OCVs in endemic areas in 2008/2009 water and adequate sanitation and hygiene (WASH) as [26]. Two additional surveys using an almost identical the mainstay to prevent cholera [15]. Official recommen- instrument were conducted in 2010 in endemic set- dations also include the use of oral cholera vaccines tings in western Kenya and southeastern Democratic (OCVs) as a supplementary public health tool for pre- Republic of Congo (SE-DRC). These three databases emptive or reactive control of cholera outbreaks [16]. on community views of cholera have been analyzed with a focus on site-specific similarities and differen- Professional versus community-reported burden of cholera ces [27,28] (Merten S, Manianga C, Weiss MG, Lapika B, The burden of cholera may be characterized with re- unpublished data). A second set of analyses has examined ference to professional indicators, and it may also be sociocultural determinants of anticipated OCV acceptance Schaetti et al. BMC Medicine 2013, 11:206 Page 3 of 16 http://www.biomedcentral.com/1741-7015/11/206 in all three settings [29-31], and of OCV uptake